Provider Demographics
NPI:1619572195
Name:KELLER, COURTNEY (PHARMD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-2127
Mailing Address - Country:US
Mailing Address - Phone:879-538-5414
Mailing Address - Fax:
Practice Address - Street 1:300 S SCHOOL ST
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638-2127
Practice Address - Country:US
Practice Address - Phone:870-538-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD150851835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPD15085OtherPHARMACIST LICENSE